Chromosome studies in patients with defective reproductive success.

PROBLEM: The objective of this study was to evaluate the contribution of chromosomal anomalies to decreased fertility in humans. METHOD OF STUDY: In order to investigate the aetiology of infertility in our population and to assess the karyotype in a group of infertile couples and individuals with fertility problems, 782 persons (259 couples, 158 male and 106 female) with different clinical diagnoses of sterility and infertility were analysed cytogenetically. RESULTS: The overall frequency of major chromosomal aberration was 13.1% (103/783), which suggests that fertility or sterility problems in this population are due to chromosomal aberrations. Couples experiencing repeated spontaneous abortions, having malformed children or having sterility problems had chromosomal abnormalities in 18.0% (47/259 couples) of the population studied, and constituted chromosomal disorders occured in couples seeking IVF and ICSI with prevalence of 22.2% (8/38 couples), especially minor mosaicism of sex chromosomes in the female partners. The prevalence of chromosome abnormalities in infertile men was 17.7% (28/158), and in subfertile females, it was 26.4% (28/106). CONCLUSIONS: These results could indicate an increased tendency to miotic sex chromosome non-disjuction in humans.

Modulation of perforin expression in the decidual and peripheral blood cytotoxic lymphocytes in culture.

PROBLEM: Perforin (P) is a cytolytic molecule located in intracellular granules of cytotoxic lymphocytes both in the peripheral blood and decidua of pregnancy. The aim was to analyze the kinetics of P expression during in vitro culture and modulation of P expression by adherent cells, their supernatants and mitogen (PHA) stimulation. METHOD OF STUDY: P (intracellular antigen) was detected by flow cytometry in the suspension of first trimester pregnancy peripheral blood lymphocytes (PBL) and decidual lymphocytes (DL). RESULTS: A decrease of the percentage of P+ cells was obtained after 1 hr incubation and was prevented by addition of 30% of decidual adherent cells (DAC) or their supernatants. Upregulation of P expression was obtained when, in addition to adherent cells, DL and PBL were stimulated by PHA. DAC present in the culture in physiological concentrations prevent downregulation of P expression. CONCLUSION: DAC located in the vicinity of decidual cytotoxic lymphocytes, owing to their unique ability to produce a wide range of substances on demand, contribute to the high level of P expression in the decidua of pregnancy.

Down-regulated expression of perforin-positive/CD16+ cells in the peripheral blood lymphocytes in the first trimester of pregnancy and up-regulation at the end of pregnancy.

PROBLEM: Immunophenotypic profiles of perforin (P)-positive peripheral blood lymphocytes in the first trimester and at the term of human pregnancy were analyzed. METHOD OF STUDY: Perforin expression in peripheral blood lymphocyte subsets was measured by simultaneous detection of P (intracellular antigen) and cell-surface antigens (CD3, CD4, CD8, CD16, and CD56) by flow cytometry in nonpregnant (NP) and pregnant women in the first trimester (FTP) and at the time of parturition (TP). RESULTS: The percentage of total P+ cells in peripheral blood compared to nonpregnant women was slightly lower in the FTP but significantly higher at TP. Perforin-positive cells were significantly elevated in T lymphocyte subsets (CD3+P+, CD4+P+, CD8+P+) in both the FTP and TP groups, as was the percentage of CD56+P+ cells. Profound changes in the CD16+ subpopulation were found in the FTP group compared to both the NP and TP groups (a drastic decrease of CD16+P+ cells; CD16+ cells among P+ cells; P+ cells among CD16+ cells). A considerable part of CD3+ cells in both the FTP and TP groups are CD3+CD56+P+. The average fluorescence intensity (AFI) for P (a measure of P content per cell) was significantly decreased in FTP and increased in TP groups. CONCLUSIONS: The CD16 molecule is Fc gamma RIIIA which is the only Fc receptor responsible for antibody dependent cell-cytotoxicity (ADCC) of NK and T-cells. In the first-trimester human pregnancy this mechanism is severely down-regulated compared to both the NP and TP groups.

Quantitative analysis of constitutive heterochromatin in couples with fetal wastage.

PROBLEM: Heteromorphism of constitutive heterochromatin is a stable evolutionary feature that is thought to cause no phenotypic alterations. Nevertheless, the role of constitutive heterochromatin is still unknown. The instability of constitutive heterochromatin was generally restricted to T-lymphocytes and was associated with variable immunodeficiency. The heterochromatin regions of chromosomes 1, 9, 16, and Y have been postulated to play a role in the immune response and during early embryo development. METHOD OF STUDY: To investigate a possible influence of constitutive heterochromatin in human reproductive ability, quantitative analysis of constitutive heterochromatin in human chromosomes 1, 9, 16 and Y was done. Thirty couples were divided into two groups, owing to the clinical heterogeneity of their reproductive disorders. The first group included couples with two or more spontaneous abortions as the only pregnancy outcomes, and the second group included couples with a stillborn child with or without malformations. In the control group were couples with one or more healthy children without a history of fetal wastage. All of the persons in this study had normal karyotypes. The amount of constitutive heterochromatin was expressed by relative value using the simple transformation [q/(p + q)]. This value, obtained on GTG-banded metaphase chromosomes, represented an indirect measure of heterochromatin content. The Y/F index was used to express the relative amount of heterochromatin in chromosome Y. RESULTS: There was a significant increase in the heterochromatin content of the chromosomes 16 homologue pair in males and females with a stillborn or a stillborn malformed child (P < 0.01) and an increase in total heterochromatin cell content compared to controls (P = 0.005). The same couples had significantly increased mean maximal heterochromatin content in the potential zygotes (P < 0.02). The couples who experienced spontaneous abortions only had a minimal total heterochromatin content in the potential zygotes (P < 0.05). The Y/F index was significantly lower in the males in both groups compared to controls (P1 < 0.02; P2 < 0.02). CONCLUSION: The quantitative analysis of constitutive heterochromatin could be valuable in predicting pregnancy outcome.

Management and complications of urolithiasis during pregnancy.

OBJECTIVE: To identify all pregnant women with urolithiasis, and to determine the mode of diagnosis and treatment with reference to obstetric outcome. METHOD: From January 1, 1986 to December 31, 1991, relevant medical records were retrospectively analyzed. RESULTS: Among 21,597 deliveries 10 pregnant women were diagnosed as having urolithiasis. They constituted 0.04% of all women who delivered at the Department of Obstetrics and Gynecology in Rijeka during this period. Conservative treatment was successful in 5 patients. Ureteral stents were inserted in 3 patients, nephrostomy was performed in 1 patient and a nephrectomy was necessary in 1 patient because of a nonfunctional kidney and chronic pyelonephritis. CONCLUSION: In our series all applied procedures in diagnosis and treatment of urolithiasis resulted in favorable maternal and perinatal outcome.

An immunohistochemical study of leucocytes in human endometrium, first and third trimester basal decidua.

An immunohistochemical quantitative study of leucocyte subpopulations on fresh human endometrium and on biopsy specimens of first and third trimester basal decidua in normal (uncomplicated) pregnancies was performed. The most prominent population in endometrial and decidual stroma of basal decidua are macrophages. B cells as well as gamma/delta T cell receptor positive cells were found occasionally, scattered throughout the endometrial/decidual stroma. CD3+ cells were present in a relatively small number in the endometrium as well as in the first trimester basal decidua, but their number was elevated (doubled) in the third trimester of pregnancy. CD2+ cells showed a slight increase in first trimester basal decidua when compared with both endometrium and third trimester basal decidua. Cells with positive NKH-1 marker (CD56+) showed a significant increase in the first trimester, while in the third trimester their number diminished drastically. CD56:CD3 cell ratio increased to more than five times in first trimester basal decidua, while in the third trimester basal decidua decreased drastically. The mentioned increase of CD56+ cells in the first trimester and that of CD3+ cells at term suggests that these cells could have some specific function(s). However, it still has to be established whether the described quantitative changes of decidual leucocytes in basal decidua during pregnancy are of any importance for the mechanism(s) for the fetal allograft protection.

Ectopic pregnancy among past IUD users.

The relationship between return to fertility and pregnancy outcome in women with IUD removal for planned pregnancy as well as the frequency of ectopic pregnancy among all former IUD users in comparison with the general population was studied. The cumulative conception rate in the group of women with IUD removal for planned pregnancy (n = 748) was 93.7% after 5 years, 93.4% being intrauterine and 0.3% ectopic. Rates of ectopic pregnancy in women with IUD removed for planned pregnancy were 2.7/1000 women, 3.6/1000 deliveries and 2.9/1000 pregnancies vs. 3.9, 13.4 and 5.6 in the general population. Only when the number of deliveries is used as denominator, have these differences reached statistical significance (P less than 0.05). Except for bleeding/pain and PID removals (6.0 vs. 3.9), in all other groups of former IUD users the incidence of ectopic pregnancy was also lower than in the control group. From the results of this study it was concluded that former IUD users are not at an increased risk for ectopic pregnancy.

[Family planning]. / Planiranje obitelji.

According to the fact that a great majority of women have expressed their wish to have only two children, two main questions have arised: what are the means that women use to limit their family size and what are the acceptable measures which the society can undertake to avoid further decline of crude birth rate in order to attain a stable population. Except for Kosovo and Macedonia, namely, in all other parts of Yugoslavia depopulating trends are present. Adequate data about contraceptive prevalence are not available, and according to some partial data, even among the women wanting no additional children, the percent of those planning no use of contraception is as high as 17.3 and further 21.2% are planning to rely on less effective contraceptive methods. The result of this situation is a relatively high number of induced abortions in Croatia 1989: 43227 or 77.7 per 100 live births). To improve this unfavourable situation, medical profession has to promote a wider use of contraception in general, particularly with more effective methods. Unfavoured decline of crude birth rate could be corrected, however, only through complex activities of long duration in order to achieve thorough improvement of the standard of living. With these improved living conditions more women would, most probably, want to have more than two children, thus avoiding the present depopulating trends in some parts of the country. On the other hand, any restriction of legal rights and availability of fertility regulation methods would be fully anachronistic and therefore unacceptable, since the only predictable result would be the increase of illegal abortions with all the well-known health risks and life-threatening conditions.

The effect of adding copper onto Lippes Loop IUDs: results from a ten-year study in Yugoslavia.

The present study is the first randomized ten-year comparison of the standard, non-medicated Lippes Loop D and the same device with the addition of 200 mm2 of copper in the form of copper sleeves. The devices were randomly inserted immediately after first trimester medical termination of pregnancy. Out of 400 postabortal IUD insertions, 371 were followed for up to ten years. Gross cumulative life-table accidental pregnancy rates after one year of use were 0.56 for the copper-bearing Lippes Loop and 4.63 for the standard Lippes Loop. After two, four and ten years, these rates were 1.24, 2.70 and 3.62 and 6.03, 7.58 and 14.94, respectively (in all comparisons, rates were significantly different at the 0.05 level or lower). At each time interval, expulsion/displacement rates were 4.49, 4.49, 5.23 and 6.32 for the copper-bearing Lippes Loop and 12.61, 13.29, 15.46 and 19.79 for the standard Lippes Loop (rates were significantly different at the 0.01 level or lower). Differences in removal rates for bleeding and/or pain were not significantly different at any of the follow-up intervals. The lower event rates for copper-bearing Lippes Loop D users indicates that the addition of copper to the Lippes Loop IUD may result in better long-term efficacy profiles for this device among postabortal women. The results also suggest that large, medicated IUDs may be more efficacious for women with larger uteri who often experience higher failure rates due to expulsion or displacement of smaller IUDs into the lower uterine segment.

Cells adherent to copper-bearing intrauterine contraceptive devices determined by monoclonal antibodies.

The presence of nucleated cells adherent to copper-bearing IUDs removed from successful IUD users, as well as from those IUD users with accidental pregnancy, was determined by a panel of monoclonal antibodies. A significant decrease in the percentage of CD3+ cells-mature T lymphocytes was found in the cell population adherent to IUDs removed from pregnant compared to non-pregnant uteri (43 +/- 2.6 vs 34 +/- 1.5). Among these cells, the percentage of CD4+ cells was increased (from 22.9 +/- 1.9 to 30.4 +/- 2.0), and CD8+ was decreased (from 23 +/- 0.9 to 10.8 +/- 1.2). The percentage of HLA-DR+ cells was also decreased (from 24.3 +/- 1.7 to 16.7 +/- 1.8). B4+ cells (B lymphocytes) were present in a similar percentage on IUDs removed from pregnant as well as from non-pregnant uteri. Thus, the uterine cavity in the presence of an IUD, contains a consistent population of immunologically competent cells. The question still remains, whether the change in the number of nucleated cells present in the uterine cavity with an IUD could contribute to its antifertility effect.

[Fetal death in the 20th to the 36th week of pregnancy]. / Smrtnost ploda u trudnoci od 20. do 36. tjedna.

In the period from 1986 to 1988, intrauterine fetal deaths from 20-36 weeks of gestation and 500 gm and more birth weight were analysed in a prospective study from the clinical and pathomorphological point of view. There were 57 such fetal deaths or 7.96% of the total number of 716 births till the 36th week of gestation, while 42.4% of women with the intrauterine fetal loss were cigarette smokers during pregnancy vs. 29.1% of such women among all those who gave birth during the same period. Smokers faced a relative risk of 1.8 for the fetal loss between the 20th and the 36th week of gestation. From the clinical standpoint, the cause of death was presumed in 40 or 71.4% of cases, while only in 24 or 42.1% of autopsies could the pathomorphological disorder be considered the cause of the intrauterine death. In 47 or 82.5% of cases, the observed pathomorphological disorders of the placenta, fetal membranes or the umbilical cord could also have contributed to the fetal death. Most often, i.e. in 20 or 35.1% of cases, chorioamnionitis was diagnosed and in 13 (22.3%) cases disorders of the placental circulation. In 7 cases (12.3%) neither clinical nor pathomorphological potential cause of death could be found. From the health care point of view it is important to find out those risk factors of fetal mortality which are preventable. Smoking during pregnancy could be the most preventable risk factor of fetal death.

[Health risks in intrauterine contraception]. / Zdravstveni rizici intrauterine kontracepcije.

From 1968 till 1987, 8514 first insertions of different IUDs were performed; 7315 IUD users were regularly followed-up. In 4269 cases non-medicated and in 3046 cases medicated IUDs were inserted. All women were classified according to age, parity and the number of previous abortions. In the women analysed only one cervical perforation was found 3 months after the insertion of TCu 380 Ag (secondary perforation). In the group of non-medicated IUD users till the cut off date (February 29, 1988) 377 (8.8%) pregnancies were registered of which 10 were ectopic; at the same time there were 104 (2.4%) cases of PID. In the group of medicated IUD users 160 (5.3%) pregnancies with 11 ectopic and 90 (3.0%) cases of PID were observed. According to the age of users, in the group of women in their teens pregnancies appeared more often than in the older users, independent of the type of the IUD used. This difference was statistically significant (p less than 0.05). The highest percent age of PID was registered in mulliparous medicated IUD users: the difference in the PID appearance in nulliparous and multiparous medicated IUD users has also shown a statistical significance. Gross cumulative rates after 10 years of use fo non-medicated IUDs were 12.5 for pregnancy and 4.6 for PID, and after 15 years 14.6 and 6.2, respectively. For medicated IUDs after 10 years of use these rates were 9.4 for pregnancy and 8.3 for PID.

A three-year evaluation of TCu 380 Ag and multiload Cu 375 intrauterine devices.

A randomized, comparative, multicenter clinical trial of TCu 380Ag and Multiload Cu 375 intrauterine devices (IUDs) was conducted. Safety and acceptability were evaluated through three years following insertion in 884 patients. The two IUDs were similar with respect to all event rates. Thirty-six month life table pregnancy rates were 0.6 per 100 TCu 380Ag users and 1.8 per 100 Multiload Cu 375 users. Continuation rates were 67.4 and 61.4 per 100 users of the respective devices at three years after insertion.

Return to fertility after IUD removal for planned pregnancy.

The ability to conceive after discontinuing contraceptive practice is an important concern for women who have not completed their families. This paper focuses on 576 women who had their IUDs removed for planned pregnancy. The data from this study add further evidence that fertility subsequent to IUD removal is not impaired. Among these women followed-up, 94.3% conceived. The majority of these conceptions (55.9%) occurred during the first three months after IUD removal. In addition to analyzing conception rates, there were four factors that were considered in relationship to return to fertility. These were age at removal, duration of use, type of IUD (medicated vs non-medicated) and timing of insertion (interval vs postabortion). Age at removal was the only variable which seemed to influence conception rates.

An evaluation of the TCu 380Ag and the Multiload Cu375.

The TCu 380Ag (Outokumpu Oy, Pori, Finland) and the Multiload Cu375 (Multilan, Organon, Oss, The Netherlands) were evaluated in 1477 women in a multicenter clinical trial. The intrauterine devices showed similar, low-event rates. Cumulative life-table pregnancy rates were less than 1.0, and continuation rates were approximately 90 per 100 women at 1 year after insertion. The risk of subsequent hospitalization or pelvic infection was low.

PIP: This study evaluated the effectiveness, safety, and acceptability of the TCu 380Ag and the Multiload Cu375 IUDs in a multicenter international trial involving 1499 acceptors. The 2 devices were randomly assigned to women who entered the trial at 5 centers in Yugoslavis, Panama, Costa Rica, and Egypt between September 1980 and June 1982. The median age of the 737 women in the TCu 380Ag group was 26.7 years, with an average parity of 1.8; the median age of the 740 women in the Multiload Cu375 group was 27.5 years, with an average parity of 1.9. At insertion, 6.8% of women in the TCu 380Ag group and 6.2% of those in the Multiload Cu375 group complained of mild pain, 1.1% of women in both groups reported moderate pain, and there were no reports of severe pain. 1-year bleeding and pain removal rates were 3.8; removal rates for other medical reasons were less than 1.0/100 women. Significantly more women in the TCu 380Ag group reported intermenstrual pelvic pain, but this difference was confined to women under 30 years of age. The continuation rate at 1 year was 90.9% for the TCu 380Ag group and 88.7% for the Multiload Cu375 group. These rates are considerably higher than those reported for other IUDs. Of the 7 pregnancies reported in the 1st year after insertion, 2 occurred in the Tcu 380Ag group and 5 occurred in the Multiload Cu375 group. The results from this trial suggest that both the TCu 380Ag and Multiload Cu375 IUDs provide a highly effective, safe, and acceptable method of contraception. For women who wish to achieve contraceptive effectiveness for long periods, the TCu 380Ag may be the IUD of choice. It remains effective for 10-15 years, while the Multiload Cu375 has a life span of only 3-5 years.

The effect of hydrogel on the reduction of bleeding associated with IUD use: a comparative study of the plain and Hydron-coated Spring Coil.

PIP: Alterations in the size, shape, and material composition or surface texture of IUDs, as well as the addition of medicaments, have been made to reduce bleeding, the most common side effect of intrauterine contraception. To determine if coating with a biocompatible hydrogel could diminish bleeding associated with the use of Spring Coils, these devices were randomly assigned to 464 women following an induced abortion; 241 women received the plain Spring Coil, 223 the Hydron-coated Spring Coil. The age/parity distribution and previous abortion experience of the 2 groups of women were almost identical. 1- and 2-year rates of pregnancy, expulsion, and removal for bleeding/pain were compared using life table analysis; differences between the 2 user groups were not significant. Menstrual pattern changes were also examined in terms of the women's perceptions of changes in their cycle length, amount of flow and duration, as well as episodes of intermenstrual bleeding. Only the increase in menstrual flow duration at 1 year follow-up was significantly lower among the Hydron-coated Spring Coil users than among women using the plain device. From the results of this study, it is unlikely that a modification to the surface material such as coating with hydrogel will significantly reduce bleeding associated with the use of the Spring Coil IUD.^ieng

[Fertility capability after the discontinuing use of various methods of fertility control]. / Fertilna sposobnost nakon prekida upotrebe razlicitih metoda za kontrolu fertiliteta.

The author draws attention to difficulties in assessing the degree of fertility after the use of various contraception methods, because prior to their application the women's initial fertility is not exactly examined. He gives a critical review of the experience reported so far on fertility after the interruption of hormonal and intrauterine contraception, sterilization, and artificial abortions. His conclusions is that none of the temporary contraception methods represents a considerable risk relating to future fertility if in each woman contraindications for their use are strictly obeyed.

[Advantages and disadvantages of IUD insertion immediately after abortion]. / Prednosti i nedostaci insercije kontracepcijskih intrauterinih ulozaka neposredno nakon abortusa.

In 672 women the interval insertion of intrauterine contraception devices (IUD) was applied: Lippes loop D in 138 women. In 530 women the insertion was applied immediately after artificial abortion: Lippes loop C in 390 and Lippes loop D in 140 cases. Data on the effectiveness of intrauterine contraception were biostatistically treated. One- and two-year gross cumulative rates of pregnancy were 4.4 and 6.4, respectively 3.7 and 6.3 for the interval insertion of Lippes loop C and D, and 2.1 and 4.5, respectively 4.2 and 11.2 for the postabortion insertion of the same devices. Two-year cumulative rates of spontaneous expulsions of 18.5 and 8.1 for interval insertions were significantly higher than in the group of women in whom the insertion of the same devices was performed immediately after abortion and in whom these rates were 11.1 and 5.9. The removal of intrauterine contraception devices because of bleeding and pain, or because of both, with the rates of 6.4 and 3.2 in 100 women after a two-year use, was less frequent in the group of women in whom interval insertion was performed than in the group of postabortion insertions with the corresponding rates of 7.3 and 9.9, respectively. To prevent repeated abortions, a frequent use of postabortion IUD insertion is recommended. Only when an intensified bleeding is expected, it is advisable to postpone insertion at least until the first menstruation.